DENNY PRICE FAMILY YMCA AFTERSCHOOL PROGRAM

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1 DENNY PRICE FAMILY YMCA AFTERSCHOOL PROGRAM REGISTRATION INFORMATION AND FORMS

INSPIRING ACHIEVEMENT, BELONGING AND CONNECTEDNESS Parent Information Registration Quick View REGISTRATION Complete the registration application and submit to the YMCA.

2 INSPIRING ACHIEVEMENT, BELONGING AND CONNECTEDNESS Parent Information Registration Quick View REGISTRATION Complete the registration application and submit to the YMCA. A new enrollment form is required for each program every year. REGISTRATION BEGINS JULY 13, 2018 Current immunization records must accompany your registration. A $25 non-refundable registration fee is required. PROGRAM BEGINS AUGUST 15, 2018 Conformations & Tax Statements Please keep any receipts or transactions made after registration. Please keep all cancelled checks, payment receipts or bank statements as documentation of childcare payments. Admission Policy The Denny Price Family YMCA generally admits children K-5 grade. The Y is open to all youth regardless of race, gender, religious belief or income. The Y will address children with additional needs on a per request basis. Upon reasonable notice, efforts will be made to accommodate your request. The safety and well-being of all must be maintained. For more information see the Americans with Disabilities Act in the parent handbook. Outside Contact Between Staff & Children Y staff are prohibited from having outside contact with children in Y programs. This includes, but not limited to, birthday parties, babysitting, sleepovers, transportation and any non-y events. Any exceptions require a written explanation prior to an event and are subjected to administrator approval.

Payments Payments must be made through Electronic Funds Transfer (EFT) or advance payment for the entire program made in full. Weekly bank drafts will be made on Wednesday for the following week.

3 Payments Payments must be made through Electronic Funds Transfer (EFT) or advance payment for the entire program made in full. Weekly bank drafts will be made on Wednesday for the following week. Any change to your bank draft information must be received at least 2 weeks prior to the date you wish the change to take effect. If your payment is returned for non-sufficient funds (NSF), your payment amount along with an NSF service fee will need to be paid at the member service desk before your child can return. For further details, please see the parent handbook. parent handbook. Program Fees Y Household & Single parent Family Member $50.00 per week $5.00 discount for each additional child Non Member & Youth Member $75.00 per week $5.00 discount for each additional child Cancellations/Refunds Refunds will not be given, and no adjustments will be made for missed or partially attended weeks. Written notification of your intent to drop out of the program must be given at least 2 weeks prior to your intended last day. Program fees during the Afterschool program will not be increased when we have No School Fun Days, Breaks & Camps.

4 Afterschool Program Denny Price Family YMCA Afterschool Program Enrollment Forms (please print & return pages 1-7) A. Participant Information School Attending Child First Name: Last Name: Date of Birth / / Age: Gender: Child lives with Mother Father Both Other Parent/Guardian # 1First Name Last Name: *This person will be the first we try to contact when needed Home Address: City State Zip Home Phone: Cell Phone Business Name and Address: Work Phone: Parent/Guardian # 2First Name Last Name: Home Address: City State Zip Home Phone: Cell Phone Business Name and Address: Work Phone: B. Emergency Contact/Others Authorized to pick Child Up The Y can only release your child to those listed on this form, they must provide a photo ID at the time of pick up. Contact the Y director to make changes to this information. #1 First Name Last Name: Home Phone: Cell Phone Relationship to child #2 First Name Last Name: Home Phone: Cell Phone Relationship to child #3 First Name Last Name: Home Phone: Cell Phone Relationship to child C. Participant Health History Child s Doctor: Address: Phone: Circle any conditions that your child has experienced: Asthma Autism Diabetes Epilepsy/Seizures ADD/ADHD Cerebral Palsy/ Other Motor Disorder Cognitive or Learning Disabilities Status of Vision, Hearing, speech to Note Non-Food Allergies (list) Food/Milk Allergies (list) If your child has food allergies or dietary restrictions, attach a statement from a medical professional. (REQUIRED) My child carries an epi-pen, inhaler or other medication. (additional medication form is required) Other conditions to note: Please provide symptoms and/or special instructions for any condition marked above( Additional form is required and notes may be attached) Denny Price Family YMCA Page 1 of 7

5 Check any of the following that relate to your child: Fears we should be aware of: An event in your child s life that may have been particularly upsetting: Social or emotional characteristics you would like to note: Other conditions requiring special care or additional information you feel would be helpful. Please initial each of the following: I have provided a copy of my child s immunization records along with this form (required to register) I authorize Y staff members to apply sunscreen to my child as needed. Parent must supply sunscreen. I authorize the Y staff members to apply bug repellant to my child as needed. D. Agreements I will notify the staff of any changes in the registration information. I consent to my child s participation in the Y program and assume the risks involved. I attest and verify that I have knowledge of the risks involved in program activities and I give my child authorization to participate in such activities. In the event that I cannot be reached to make arrangements for emergency medical attention at the time of illness or accident, I hereby authorize the Y to take my child to the nearest facility for medical attention. I understand that it is my responsibility that my child is signed in upon arrival to the program, and signed out before leaving each day. I understand that I cannot leave my child at the Y or program site unless a Y program staff member is there to receive and supervise my child. There must be an exchange of responsibility from an authorized individual to a Y staff member. I understand that the Y has no Outside Contact Policy between Staff and Children. Y Staff are prohibited from having outside contact with children in Y programs. Includes but is not limited to: babysitting, sleepovers, transportation or other non-y events. I understand that state law mandates the Y to report any suspected cases of child abuse or neglect to the appropriate authorities for investigation. enidymca.org or I can request a printed copy from the Y. By signature and of free will I do hereby agree to indemnify and hold harmless the Y for any and all claims or demands, cost of expense arising out of any injury or damage sustained by me or any party I am responsible for. I understand that even when every reasonable precaution is taken, accidents can sometimes happen. Therefore, in exchange for allowing my child to participate in Y programs, I understand and expressly acknowledge that I, for myself and for anyone entitled to act on my behalf, waive and release the Y, sponsors, representatives and successors from all claims or liabilities of any kind arising out of my child s participation in activities at or sponsored by the Y. I further agree to indemnify and save harmless the Y from any claims or demands arising out of such injuries or losses. I understand that this release includes any claims based on negligence, action I have read and understand the statements above regarding YMCA policies and procedures. Print Name Sign Name Date Denny Price Family YMCA Page 2 of 7

6 E. Accounting Policies and Payments 1. Acceptable payment form is: Electronic Funds Transfer (EFT) or advance payments made in full for entire program. 2. A $25 dollar non-refundable registration fee is due at time of registration. 3. Drafts will be made on Wednesday for the following week of care. Drafts will be made each week to hold your child s spot unless a two-week written notification has been provided for a cancellation from the program. 4. No adjustments in the weekly fee will be made for partially or non attended weeks, when care is not provided due to holidays that the Y is closed or inclement weather days. 5. Program fees are also not increased when we have No School Fun Days, Breaks or Camps. 6. The Y does not issue statements for individual tax purposes. Please keep any and all cancelled checks, payment receipts or bank statements as documentation of childcare payments. 7. Refunds are typically not given. A Refund Request Form may be obtained and returned to the member service desk and all refunds are at the discretion of the Executive Director. 8. If your payment is returned for insufficient funds (NSF), your payment along with an NSF service fee of $20 will need to be paid to the member service desk before your child can return. Any change to your bank draft information must be received at least 2 weeks prior to the date of the change for the change to take effect. 9. A late pick up fee of $1.00 per minute will be assessed for each minute after 6:00 p.m. that your child remains in our care. This fee will be drafted from the account on file. If there is no account on file due to payment in full, this charge must be paid at the member service desk, and your child will not be allowed to attend until the amount due is satisfied. Bank Account Information: First Name Last Name Name(s) of participants whom you are paying for: I will make advanced payment in full for entire school year at the Y Member Service Desk at the time of registration. I receive third party payments, such as DHS, I understand that I am responsible for all copayments & set up on draft. I will be paying through Electronic Funds Transfer. Information below is required along with a Voided Check Bank Name Bank City/ State Type of Account: Checking Savings Credit Card (form at front desk) Print your name as it appears on the bank account: Financial Institution Routing Number: Account Number I (we) request and authorize the Denny Price Family YMCA to charge the checking/savings account listed below for program fees. I (we) understand that these charges are continuous and ongoing until the end of the program, or the Y receives the proper cancelation notice of 2 weeks. Print Name of Authorized Signature Authorized Signature Date Print Name of Joint Account Holder Joint Account Holder Authorized Signature Date (if applicable) (if applicable) We have read the Accounting Policies and agree to comply with all payments and policies. Print Name Authorized Signature Date Denny Price Family YMCA Page 3 of 7

7 Lice Policy What happens when a child is found to have head lice? The program undertakes the following steps to ensure that a clearly defined process is followed when a child is found to have head lice: Day 1: The student is given a brief, age appropriate explanation about the head lice. A letter to Parents of a Child Found to have Head Lice is sent home with the child. The letter informs the parents that their child has head lice and advises them that the child must commence head lice treatment that night before returning to the program the next day. Parents of the other students in the class are sent an information letter on the same day, asking them to check their child's hair for head lice. Day 2: The child then returns to the program with the completed Confirmation that treatment has been preformed. If nits or eggs are found within ¼ in. of the scalp during a visual dry inspection child will be sent home for additional treatments. Day 3 TO DAY 7 Parents continue using a nit comb with hair conditioner to comb out eggs to ensure life-cycle of louse has been stopped As a last resort, only where considered appropriate by the Child Care Director, the family may be referred to the Health Department, e.g. where a child is experiencing ongoing psychological distress, or if infected sores result from untreated head lice infestation and the sores remain untreated. Informing parents of this decision prior to referral is at the discretion of the Director. Parent or Guardian Date Denny Price Family YMCA Page 4 of 7

8 Climbing Wall Release of Liability NOTICE: This is a legally binding contract. In consideration of my being permitted by The Denny Price Family YMCA of Enid, Oklahoma Not-For-Profit Corporation (hereinafter the YMCA ), to climb at one of its facilities and/or participate in any program offered by the YMCA, including its climbing school, I agree to the following waiver and release and I make the following representations: (initial) I hereby acknowledge the inherent extreme risk in rock climbing, including climbing on artificial surfaces, I realize that those risks include, but are not limited to: falls from or contact with walls and equipment, bad decision-making, inattetion of belayers or actions of other climbers, misuse or failure of equipment, holds which may have become loose or damaged, and freakish accidents which cannot be foreseen. I acknowledge that the above list is not inclusive of all possible risks associated with the use of the facilities, and/or the sport of climbing and I agree that said list in no way limits the extent or reach of this Release. I voluntarily assume all such risks with full knowledge and appreciation of the danger and risk involved I voluntarily agree to assume all risk of personal injury. Including paralysis and death, that may occur while I am in the facility, or participating in any event or program or while I am climbing anywhere at any time. Whether or not under supervison of YMCA personnel. I hereby knowingly and intentionally waive and release and agree to indemnify, hold hamless and defend YMCA, it successors, assigns, officers, employees, and wall designers and builders, hold manufacturers lessors and agents from liability from any such damage, injury paralysis or death which may result. This Release shall be effective even though said loss, damage, or injury results or has resulted from the negligence, wrongful acts, omissions, breach of warranty or strict lort liability of YMCA ot the other parties released. I am in good health and have no physical limitations which would effect my safe use of the facilities. I agree to pay attention to the state of any ropes, anchors, and other equipment that I may use, and to advice staff member if I do any damage or notice any damage. I certify tha I have read the posted rules, and agree to abide by these rules and any future rules, and if staff makes a specific request of or instruction to me, I agree to comply. I understand that indoor climbing is not the same as outdoor climbing, which requires additional skills, and I agree to see qualified instruction before attempting to climb outdoors. I have read and understand the safety policies for the YMCA climbing program and agree to comply with those policies. I am at least eighteen (18) years of age and otherwise legally competent to sign this agreement. This release shall be effective and binding upon me and upon my assigns, heirs, representative, executors, and administrators. If under the age of 18, this release must be signed by the parent/guardian of the minor, and I agree to indemnify and hold harmless the YMCA and the other released parties in the event a minor member of my family sues them or any one of them. I understand that this release is a contract. I expressly state that I have read, understand and am familiar with all of the provisions and that I signed it of my own free will. Signature: Printed Name: Date: Home Phone: Work Phone: Date of Birth: Witnessed by: TO BE READ AND SIGNED BY PARENT/GUARDIAN OF MINOR: I hereby state that I am the paint or guardian of the minor whose signature appears above. I am familiar with and consent and agree to the terms and provisions set forth in this release. Signature of Parent or Guardian: Printed Name: Denny Price Family YMCA Page 5 of 7

9 Bounce House Release of Liability NOTICE: This is a legally binding contract. In consideration of my being per mitted by The Denny Price Family YMCA of Enid, Oklahoma Not-For-Profit Corporation (hereinafter the YMCA ), to participate at one of its facilities and/or participate in any program offered by the YMCA, including its Birthday Party, After school or Day Camp programs I agree to the following waiver and release and I make the following representations: (initial) I voluntarily agree to assume all risk of personal injury. Including paralysis and death, that may occur while I am in the facility, or participating in any event or program or while I am jumping at any time. Whether or not under supervison of YMCA personnel. I hereby knowingly and intentionally waive and release and agree to indemnify, hold hamless and defend YMCA, it successors, assigns, officers, employees, and hold manufacturers lessors and agents from liability from any such damage, injury paralysis or death which may result. This Release shall be effective even though said loss, damage, or injury results or has resulted from the negligence, wrongful acts, omissions, breach of warranty or strict lort liability of YMCA ot the other parties released. I am in good health and have no physical limitations which would effect my safe use of the facilities. I agree to pay attention to the state of the equipment that I may use, and to advice staff member if I do any damage or notice any damage. I certify that I have read the posted rules, and agree to abide by these rules and any future rules, and if staff makes a specific request of or instruction to me, I agree to comply. I am at least eighteen (18) years of age and otherwise legally competent to sign this agreement. This release shall be effective and binding upon me and upon my assigns, heirs, representative, executors, and administrators. If under the age of 18, this release must be signed by the parent/guardian of the minor, and I agree to indemnify and hold harmless the YMCA and the other released parties in the event a minor member of my family sues them or any one of them. I understand that this release is a contract. I expressly state that I have read, understand and am familiar with all of the provisions and that I signed it of my own free will. Signature: Printed Name: Date: Home Phone: Work Phone: Date of Birth: Witnessed by: TO BE READ AND SIGNED BY PARENT/GUARDIAN OF MINOR: I hereby state that I am the paint or guardian of the minor whose signature appears above. I am familiar with and consent and agree to the terms and provisions set forth in this release. Signature of Parent or Guardian: Printed Name: Date: Witnessed by: Denny Price Family YMCA Page 6 of 7

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After School Program Registration Form

2018-19 After School Program Registration Form Office Use Only Date registered: _ Staff: Please fill out this form entirely. If there are blanks it may slow down your child s enrollment process. If a line